Monday, July 16, 2018

Report Reveals Patterns of Potentially Unsafe Use of Zolpidem

Despite FDA recommendations that the hypnotic zolpidem be used for short-term treatment of insomnia, most patients report sustained use, according to a report published today in JAMA Internal Medicine. The report also found evidence that women may be taking zolpidem above the recommended dose.

In 2013 the FDA recommended that manufacturers of some zolpidem products update their medication labels to lower the recommended initial dose of the medication for women after evidence at the time suggested that women eliminate zolpidem more slowly from their bodies than men. The FDA informed manufacturers that the recommended dose of zolpidem for women should be lowered from 10 mg to 5 mg for immediate-release products (Ambien, Edluar, and Zolpimist) and from 12.5 mg to 6.25 mg for extended-release products (Ambien CR); the FDA recommended that health care professionals also consider prescribing the lower doses for men, according to the 2013 safety announcement.

“These precautions were intended to reduce the risks of next-day impairment, abnormal behavioral changes, and dependency,” study authors Thomas J. Moore, A.B., of the Institute for Safe Medication Practices and Donald R. Mattison, M.D., M.S., of Risk Sciences International in Ottawa, Canada, explained in the JAMA Internal Medicine report. Moore and Mattison used the U.S. Medical Expenditure Panel Survey for 2015 to examine how patterns of reported use compared with the FDA recommendations.

Overall, 3.8 million adults aged 18 to 85 years reported filling one or more prescriptions for zolpidem in 2015. Women were nearly twice as likely as men to report taking zolpidem, they noted. Additional analysis revealed that 68% of women were taking 10 mg immediate release or 12.5 mg extended-release products—above the recommended initial dose of 5 mg and 6.25 mg, respectively. More than 68% of those exposed to zolpidem reported sustained use (defined as three or more prescriptions or use over 61 days or more); the sustained-use zolpidem group reported a median of 192 days’ supply.

“Although efficacy declines substantially after 14 days of continuous administration, most zolpidem patients reported sustained use, with increased risk of dependence, given that zolpidem is a class IV-controlled substance,” the authors wrote.

For more on hypnotics, see the Psychiatric News article “Study Finds Rising Long-Term Use of Hypnotics.”

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Friday, July 13, 2018

Avatar-Guided Virtual Reality Therapy Found to Reduce Fear of Heights

A brief psychological therapy using virtual reality (VR) can help people overcome their fear of heights, reports a randomized, clinical study published this week in The Lancet Psychiatry. The VR therapy used a digital avatar as the coach; there was no human therapist involved.

“Immersive virtual reality therapies that do not need a therapist have the potential to dramatically increase access to psychological interventions,” said lead author Daniel Freeman, Ph.D., of the University of Oxford in a press release. “We need a greater number of skilled therapists, not fewer, but to meet the large demand for mental health treatment, we also require powerful technological solutions.”

For this study, 100 people with clinically diagnosed fear of heights, or acrophobia, using DSM-5 criteria were divided into two groups: one participated in the VR coaching program; the other received no treatment. All participants scored higher than 29 on the Heights Interpretation Questionnaire (HIQ), which the researchers considered as the threshold indicating a moderate fear of heights.

The VR therapy involved six 30-minute sessions over two weeks. In the first session, the virtual coach provided background information about acrophobia and how to treat it from a cognitive perspective to develop memories of safety that counteract fear associations.

The remaining sessions had the participants tour a virtual 10-story office complex and take part in activities to break down their fears while the coach provided empathic encouragement, repeated key learning points, and sought feedback on whether the participant felt safer than before. As the program progressed, the activities became more challenging, starting with simple tasks like watching a safety barrier gradually lower over the edge of a drop and then moving on to more difficult tasks like walking out on a high platform.

At the end of the study, the VR participants had an average reduction of 24.5 points on their HIQ scores compared with a 1.2-point reduction among the controls. At the two-week follow-up, 34 of the 49 VR participants had HIQ scores of 29 or lower. No adverse side effects were reported, and 44 of the 49 participants completed all six sessions.

To read more about VR, see the Psychiatric News article “Virtual Reality May Soon Become Clinical Reality in Psychosis Care.

(image: PeopleImages/iStock)

Thursday, July 12, 2018

APA Awarded $14.2 Million Grant to Improve Treatment for Serious Mental Illness

APA has been awarded a five-year, $14.2 million grant to create an educational and support system to expand access to care for the 11 million adults in this country who have serious mental illness.

The funding for the project, known as the Clinical Support System for Serious Mental Illness (CSS-SMI), was awarded by the Substance Abuse and Mental Health Services Administration. Serious mental illnesses are those that substantially interfere with major life activities and include schizophrenia, bipolar disorder, and major depressive disorder. At least one-third of people with these diagnoses do not receive treatment.

“This grant will allow APA to take a leading role in addressing serious mental illness in this country,” said APA President Altha Stewart, M.D., in a statement. “The CSS-SMI project will help us disseminate best practices for treating people who have serious mental illness and increase their access to care. I am excited to see the project unfold over the next five years.”

The project will offer expert consultation services and learning opportunities nationwide to enable clinicians—such as physicians, nurses, recovery specialists, peer-to-peer specialists, and others—to provide evidence-based care using state-of-the-art technology to treat or assist people with serious mental illness. Components include a call center as well as sophisticated internet- and app-based technologies to promote best practices in caring for these individuals, including the use of APA’s PsychPRO mental health registry.

In addition to APA, 29 partner organizations and individuals will provide expertise on clinical content, educational resources, and strategic guidance. Partners include the Academy of Consultation-Liaison Psychiatry, American Academy of Addiction Psychiatry, American Academy of Child and Adolescent Psychiatry, and the American Association of Community Psychiatrists.

Detailed information will appear in a future issue of Psychiatric News.

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Highlights From APA’s 2018 Annual Meeting: Issue #3

As ECT Marks 80th Birthday, Experts Reflect on Its Future

Researchers are using neuroimaging to determine additional ways to make this proven treatment for treatment-resistant depression even safer and more effective.

Read More >

Assembly Seeks Help for Members Appealing Insurance Denials

At its meeting in May, the APA Assembly took action on a number of issues important to the Association, the field of psychiatry, and its patients. Among them was a proposal to help members appeal denied insurance claims.

Read More >

Equine Therapy Helps Patients Overcome Range of Psychiatric Disorders

In this millennia-old practice, equine-assisted therapy promotes patients’ physical, occupational, and emotional growth.

Read More >

Identities Should Be Additive, Not ‘Either/Or,’ Say Speakers

Self-reflections shared by three speakers highlight how women of color face unique discrimination and biases.

Read More >

Taking Some Antipsychotics During Pregnancy May Raise Risk of Gestational Diabetes

Women who continue use of the antipsychotic drugs olanzapine and quetiapine during pregnancy have an increased risk of gestational diabetes, according to a study in AJP in Advance that was released at the APA Annual Meeting.

Read More >

Wednesday, July 11, 2018

ED-Administered Safety Planning Intervention Reduces Suicidal Behaviors

A brief clinical intervention in the emergency department (ED) along with structured follow-up phone calls can reduce suicidal behaviors in patients and  encourage them to use mental health services, according to a study published today in JAMA Psychiatry.

Barbara Stanley, Ph.D., of Columbia University and colleagues enrolled 1,640 adults who had been admitted to one of nine Veterans Administration EDs who had had a suicidal crisis (but who did not subsequently require inpatient hospitalization) between 2010 and 2015. Four of the EDs continued to provide their usual care for the patients, while the other five implemented a safety-planning intervention combined with telephone follow-up. 

Safety planning provides patients with a written safety plan that includes coping skills, strategies to make their environment safer, and a list of people who can provide support. The telephone follow-up consisted of at least two postdischarge contacts with a patient to monitor suicide risk, review the safety plan, and encourage continued treatment.

Six months after ED discharge, fewer patients in the safety planning group engaged in suicidal behavior compared with the usual care group (3.03% vs. 5.29%, respectively). Recipients receiving the safety-plan intervention and follow-up also had more than double the odds of attending at least one outpatient mental health visit after discharge. 

The increased visits with outpatient mental health services were not solely responsible for the reduced suicidal behaviors, the authors noted; other components of the safety-planning intervention were also contributing to patient improvements.

“Our findings are promising and indicate that safety planning and active outreach—a set of low-burden strategies—are useful components of effective suicide prevention,” Stanley and colleagues wrote. “Importantly, using the low-burden intervention in this project and others was associated with about the same reduction in suicidal behavior as more intensive and costly psychosocial interventions. If implemented broadly, [this intervention] has the potential to reduce suicidal behavior and enhance behavioral health treatment engagement, particularly during high-risk periods following ED discharge.”

To read more on this topic, see the Psychiatric News article “Emergency Department Intervention May Reduce Suicide Attempts in At-Risk Patients.” 

(image: cleanphotos/shutterstock)

Tuesday, July 10, 2018

Opioid Prescribing for Teens Exceeded CDC 2016 Guidelines for Adults

Between 2005 and 2016, opioid prescriptions for adolescents generally were written for longer than three days, and the number of prescriptions filled for four and five day supplies increased, according to a report in Psychiatric Services in Advance.

These trends occurred prior to the issuance of guidelines for opioid prescribing by the Centers for Disease Control and Prevention (CDC) in 2016 but during a period of increasing national awareness of the opioid epidemic, according to lead author Mir M. Ali, Ph.D., of the Center for Behavioral Health Statistics and Quality at the Substance Abuse and Mental Health Services Administration and colleagues. The CDC did not provide explicit opioid-prescribing guidance for individuals under age 18 in 2016 but did recommend that opioids be prescribed even more cautiously for adolescents than for adults.

Ali and colleagues measured the number of days for which opioids were prescribed for adolescents aged 12 to 17 covered by Medicaid or commercial insurance by using the 2005-2016 IBM MarketScan commercial and Medicaid databases. They identified all oral prescriptions filled by adolescents for the most commonly prescribed opioids: hydrocodone, hydromorphone, oxycodone, codeine, methadone, tramadol, and morphine. They measured average days’ supply per prescription using the following categories: one, two or three, four or five, six or seven, eight to 15, 16 to 30, and greater than 30 days.

For adolescents with Medicaid insurance, a supply of two or three days was the most common prescription range until 2016, decreasing from 50.5% of prescriptions filled in 2005 to 36.7% in 2016. Over the same period, the percentage of prescriptions with a supply of four or five days increased from 30.2% to 37.7%; even in 2016, the percentage of prescriptions written for between four days and more than 30 days exceeded 50 percent. The pattern for adolescents with commercial insurance followed similar patterns for adolescents with Medicaid, according to the report.

The rate of prescriptions written for a one-day supply remained at 1.0% to 2.0% until 2016, when the CDC guidelines were issued. In that year, they increased to 3.6%, according to the report.

The latter trend is hopeful. “The uptick in one-day opioid prescriptions in 2016 … may indicate that some prescribers are increasingly trying to minimize prescribing to adolescents,” the researchers stated. “As states increasingly impose days’ supply restrictions for adolescents that are often more restrictive than those for adults and as those restrictions are strictly enforced, it is possible that the increasing trend of prescribing a supply of four or five days of opioids for adolescents might reverse.”

For related information, see the Psychiatric News article “Psychiatrists Can Play Vital Role in Stemming Opioid Crisis.”
(Image: luchshen/

Monday, July 9, 2018

Rates of Routine Depression Screening on Rise but Still Low

Rates of routine depression screening among U.S. adults have increased since 2009 but remain low overall, reports a study published today in Psychiatric Services in Advance. In 2009, the U.S. Preventive Services Task Force (USPSTF) first recommended that routine depression screening be carried out in any clinical practice that has adequate depression care support in place.

The USPSTF is an independent, volunteer panel of national experts in disease prevention and evidence-based medicine. Its members are appointed by the director of the Agency for Healthcare Research and Quality, the lead federal agency charged with improving the safety and quality of the U.S. health care system.

Sandipan Bhattacharjee, Ph.D., of the University of Arizona and colleagues used data from the National Ambulatory Medical Care Survey to assess screening rates among adults 18 and older without a depression diagnosis who made an outpatient visit to a health care professional other than a psychiatrist. Of the 298,896 records of doctor visits between 2005 and 2015 that met the researchers’ criteria, 3,986 visits (1.4%) included a depression screening.

During the study period, screening rates fell from about 1.5 percent in 2005 to a low of .65 percent in 2008 and then steadily rose from 2009 to a high of 3 percent in 2015.

In addition to the 2009 USPSTF recommendation, Bhattacharjee and colleagues noted that the rise in screening rates could have been influenced by the Affordable Care Act of 2010, which mandated depression screening and other preventive care be offered at no cost. They also noted that their study period ended before USPSTF updated its recommendation in 2016 to reflect that routine depression screening should occur even in clinical practices without on-site mental health services. 

“This study observed that more time spent by the patient in the physician’s office led to higher screening rates,” wrote the researchers. “Since increasing the length of time of the actual visit to the physician may be difficult, it is recommended that other health care providers in these settings be trained to provide screening.”

To read more on this topic, see the Psychiatric News article “New Primary Care Guidelines Recommend Routine Screening for Depression in Adolescents.”

(Image: Alexander Raths/shutterstock)

Friday, July 6, 2018

Active Participation in Health Care Governance Said to Combat Physician Burnout

The loss of autonomy for physicians—as many have begun working in large health systems rather than as solo or small group practitioners—has been a key driver of physician burnout, according to the authors of a Viewpoint article in the July issue of JAMA Psychiatry.

While efforts to improve self-care have been moderately effective in addressing burnout, they fail to address its underlying cause—namely, the lack of physician autonomy in today’s large health care systems, write Frederick S. Southwick, M.D., a professor of medicine at the University of Florida College of Medicine, and Steven M. Southwick, M.D., the Glenn H. Greenberg Professor of Psychiatry at Yale University School of Medicine. In small group and solo practices, physicians were largely free to dictate how they practiced medicine, but large health care systems, by contrast, tend to be impersonal and controlling, leaving little room for physicians to decide what tests to perform, what treatments to administer, and how much time to spend with patients. 

Physicians often feel frustrated by today’s broad array of mandated regulations, required use of electronic health records, and performance expectations imposed by insurance companies, government agencies, and hospital administrators. These conditions leave many physicians feeling overwhelmed and relatively powerless. In animal and human studies, chronic stress that is experienced as uncontrollable can have highly toxic effects, the authors write. “The degree of control that an animal or human can exert over a stressor has a substantial impact on the emotional, behavioral, neurobiological, and physiological effects of that stressor.”

How can physicians take control of their work lives and prevent or reduce burnout and at the same time contribute to improvements in every process that affects patient care? The authors recommend that “health care organizations adopt a distributive leadership model that encourages physicians to actively participate in governing and improving the systems in which they work. Modern health care is highly complex and interdependent, and it is crucial to effective service provision that physicians share administrative and policy leadership positions with nonphysician health care administrators.” Also needed are “the allocation of sufficient administrative time, resources, training, and administrative support to empower physicians to lead the adaptive changes needed to fix health care delivery.” 

The authors conclude that high rates of burnout among physicians will persist until health care systems find ways to increase doctors’ sense of control and autonomy.

For related information, see APA’s Well-being and Burnout Resources, including an online well-being self-assessment tool.

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Thursday, July 5, 2018

Prenatal Exposure to Folic Acid Appears to Promote Healthy Brain Development

Increased prenatal exposure to folic acid, which is known to reduce the risk of neural tube defects, may also promote healthy brain development through adolescence, reports a study published in JAMA Psychiatry. According to the study authors, prenatal exposure to folic acid may protect against psychosis through altered postnatal cortical development. 

Some studies suggest poor maternal nutrition during pregnancy increases subsequent risks for conditions like schizophrenia in offspring; other studies have suggested that prenatal exposure to folic acid may lower the risk of language delay and autism in children. In 1996, the U.S. government mandated that all food manufacturers fortify enriched grain products with folic acid by January 1, 1998. To examine whether prenatal exposure to folic acid is associated with changes in brain development later in life, Hamdi Eryilmaz, Ph.D., of Massachusetts General Hospital and colleagues compared cortical brain development in youth who were born before, during, and after the full implementation of folic acid fortification of U.S. grain products.

Eryilmaz and colleagues analyzed multiple sets of magnetic resonance imaging (MRI) scans taken when children and adolescents born from 1993 to 2001 were ages 8 to 18: one set consisted of normal brain images taken from 292 patients seen at Massachusetts General Hospital; another set included images from 861 participants in the Philadelphia Neurodevelopmental Cohort, a study that assessed psychiatric symptoms in the study participants; and a third included scans collected of youth in an NIH study, who were born prior to folic acid fortification. 

The researchers found that cortical thickness was greatest in youth born after the implementation of folic acid fortification, intermediate in those partially exposed to folic acid fortification, and lowest in those born before fortification. Data from the Philadelphia cohort suggested delayed cortical thinning in the group exposed to full folic acid fortification was associated with a reduced risk of psychosis symptoms. “Collectively, these data suggest an association of prenatal exposure to folic acid fortification with increased cortical thickness through early adolescence, accompanied by delayed onset of cortical thinning and reduced risk of psychosis,” the authors wrote.

“While our results link prenatal exposure to folic acid fortification with changes in cortical development and with a reduced risk of psychotic spectrum symptoms, they cannot directly link folic acid exposure to reduced schizophrenia risk, since the typical age of onset for that disorder is in the early 20s,” senior author Joshua Roffman, M.D., M.M.Sc., of Massachusetts General said in a press release. “But since such symptoms in youth are on the same continuum as schizophrenia, the results hold some promise for schizophrenia prevention.” 

For related news, see the American Journal of Psychiatry review article “Prenatal Primary Prevention of Mental Illness by Micronutrient Supplements in Pregnancy.”

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Tuesday, July 3, 2018

Retinal Nerve Fiber Thickness May Offer Clues to Predict Cognitive Decline

Identifying people at greatest risk for cognitive decline as early as possible is important for developing treatments that can prevent or slow dementia. A study in JAMA Neurology suggests assessing the thickness of the retinal nerve fiber layer (RNFL)—the inner most layer of the retina—may offer some clues about those at greatest risk of future cognitive decline.

Fang Ko, M.D., of the University College of London Institute of Ophthalmology and colleagues analyzed data from UK Biobank, a large epidemiological study of UK residents aged 40 to 69. As part of this study, between September 2009 and June 2010 67,321 people underwent optical coherence testing (OCT)—a noninvasive imaging tool that can produce 3-D cross-sectional images of the retina. Study participants received cognitive tests, which measured prospective memory, pairs matching, numeric and verbal reasoning, and reaction time, at the start of the study and again during 2012-2013. The researchers focused their analysis on 1,251 people with high-quality OCT scans, who had complete baseline and follow-up cognitive evaluations, reported no neurological or ocular disease, and did not have diabetes.

The researchers found that a thinner baseline RNFL measurement was associated with worse performance on baseline cognitive tests. Moreover, a thinner baseline RNFL was significantly associated with a future decline in a greater number of cognitive tests, even after controlling for potential confounders.

“Our study strengthens the argument of an association between neurodegenerative processes that affect the brain and the eye and indicates that ... measurement of the RNFL is a potential noninvasive, relatively low-cost, and time-efficient screening test for early cognitive changes,” Ko and colleagues wrote.

For related information, see the Psychiatric News article “Dual-Task Gait Testing Identifies MCI Patients Likely to Develop Dementia.”

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Monday, July 2, 2018

FDA Approves Aristada Initio to Allow Immediate Initiation of the Long-Acting Atypical Antipsychotic

Clinicians will soon be able to offer patients with schizophrenia who are initiating the long-acting injectable atypical antipsychotic Aristada (aripiprazole lauroxil) the option of an alternative to three weeks of oral aripiprazole supplementation following the first injection. The Food and Drug Administration (FDA) has approved Aristada Initio for the initiation of Aristada, manufacturer Alkermes announced today.

This approval now makes it possible for patients to receive Aristada Initio, in combination with a single 30 mg dose of oral aripiprazole, along with their first dose of Aristada (441 mg, 662 mg, or 882 mg monthly; 882 mg once every six weeks; and 1064 mg once every two months) in a single day.

“Previously, the standard initiation regimen for Aristada included 21 consecutive days of oral aripiprazole starting with the first Aristada dose,” according to a press release issued by Alkermes. “The Aristada Initio regimen provides patients with relevant levels of aripiprazole within four days of initiation.”

Aristada was first approved by the FDA in October 2015, with dosages for use every four to six weeks, and in June 2017, the agency approved a two-month dose of the medication.

“Long-acting injectable atypical antipsychotics have an increasingly recognized role in the treatment of schizophrenia. The ability to initiate Aristada on day one may be particularly useful in the hospital setting, where more than one-third of patients initiate on long-acting therapies,” Craig Hopkinson, M.D., chief medical officer and senior vice president of Medicines Development and Medical Affairs at Alkermes, said in the Alkermes release.

According to Alkermes, Aristada Initio is expected to be available later this month.

For related information, see the Psychiatric News PsychoPharm article “Clinicians Can Also Benefit From Using Long-Acting Formulations,” by John Kane, M.D.

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Friday, June 29, 2018

Clinicians Develop New Rating Scale for Perimenopausal Depression

Key differences in depressive symptoms that arise during perimenopause (the period immediately before menopause) suggest that perimenopausal depression may be a distinct subtype of depression, but scales to measure or monitor symptoms of perimenopausal depression are lacking. A report published yesterday in Translational Psychiatry describes the development and validation of a questionnaire that clinicians or patients can use to rate the severity of perimenopausal depression symptoms.

“Having a reliable tool to aid in the diagnosis of perimenopausal depression is very important in research of this relatively neglected area of women’s health,” wrote Jayashiri Kulkarni, M.D., and colleagues at Monash University in Melbourne, Australia. “Clinically, it is very important to accurately detect and diagnose perimenopausal depression as early as possible to enable more specific treatments, such as hormone treatment strategies.”

Kulkarni and colleagues conducted an extensive literature review and relied on clinical observation and focus groups (including perimenopausal women and clinicians) to identify key perimenopausal depression symptom areas. From this research, they created a 12-item questionnaire, called the Meno-D, which asked patients to rate the severity of the following symptoms on a scale of 0 to 4: anxiety, concentration, energy, irritability, isolation, memory, paranoia, self-esteem, sexual interest, sleep, somatic symptoms, and weight changes.

The Meno-D was then administered to 93 women experiencing symptoms of perimenopausal depression, 82 of whom completed the questionnaire. While the women varied significantly in their total Meno-D scores, despite all having perimenopausal depression, they generally had above average scores related to somatic (somatic symptoms and weight), cognitive (memory and concentration), self (self-esteem, paranoia, isolation, and anxiety), sleep (sleep disturbances and irritability), and/or sexual (sexual interest and energy) symptoms.

“Previous studies have reported that women experiencing perimenopausal depression complain about physical symptoms more than cognitive ones, which are not typically included in previous scales assessing for major depressive disorder,” Kulkarni and colleagues wrote. “This may explain why perimenopausal depression is often overlooked or left undiagnosed.”

They concluded, “The Meno-D will support a growing research field, interfacing both psychiatry and endocrinology, which indicates that perimenopausal depression is a unique subtype of depression requiring a different management approach.”

To read more about this topic, see the Psychiatric News article “Discontinuing Hormone Therapy May Increase Risk of Depression in Some Women.”

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Thursday, June 28, 2018

Repetitive Transcranial Magnetic Stimulation Appears No Better Than Sham in Veterans With Depression

Repetitive transcranial magnetic stimulation (rTMS) helped more than 40% of veterans with treatment-resistant depression (TRD) to reach remission, but this remission rate was about the same as the benefit seen in veterans who received sham treatments, according to a study published yesterday in JAMA Psychiatry.

Jerome A. Yesavage, M.D., of the Department of Veterans Affairs (VA) and colleagues recruited 164 veterans with TRD (defined as failure to respond to two prior antidepressants) from nine VA medical centers. The study participants had a mean age of 55 years, 81% were men, and 77% were white. These participants were randomized to receive either left prefrontal rTMS treatment (10 Hz, 120% motor threshold, 4,000 pulses/session) or sham treatment for up to 30 treatment sessions. For both groups, treatment was delivered in five-session blocks over a period of five to 12 days. Participants who experienced remission received another six additional taper sessions over a three-week period.

At the end of the acute treatment phase, 41% of the participants in the active treatment group who finished rTMS treatment experienced remission of depressive symptoms compared with 37% in the sham group, which researchers found not to be a statistically significant difference. At the end of the six-month follow-up phase, 20% of the active treatment group sustained remission compared with 16% of the sham treatment group.

“These high remission rates suggest that veterans’ expectations of improvement and extensive attention provided by their TMS treatment team may have played a large role in the significant clinical improvements they experienced,” Yesavage and colleagues wrote.

They continued, “Achieving remission rates of 40% and over in treatment-resistant veterans is a clinically meaningful result warranting evaluation of such comprehensive approaches to treatment of patients with difficult-to-treat MDD [major depressive disorder] within the VA. Future work with rTMS may show an enhanced effect when newer coil models, better stimulus targeting, biological markers of response, higher frequency rates of stimulation, and longer duration of treatment are implemented.”

For related information, see the Journal of Neuropsychiatry and Clinical Neurosciences article “Noninvasive Brain Stimulation: Challenges and Opportunities for a New Clinical Specialty.”

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Wednesday, June 27, 2018

Depression Severity May Predict Akathisia Risk With Aripiprazole Augmentation in Older Adults

Adding the antipsychotic aripiprazole to an antidepressant regimen can benefit older patients with treatment-resistant depression, but the strategy comes with risks: aripiprazole augmentation can cause extrapyramidal symptoms, such as akathisia and parkinsonism, according to a study in the Journal of Clinical Psychiatry. Thus, clinicians need to pay close attention when prescribing aripiprazole to older patients with more severe depressive symptoms.

Jonathan H. Hsu, M.D., of the University of Toronto, and colleagues analyzed data collected during a randomized, controlled trial evaluating the efficacy and safety of aripiprazole augmentation for adults aged older than 60 years with treatment-resistant depression. Patients who did not achieve remission after receiving venlafaxine extended-release (up to 300 mg/day) for 12 weeks were randomly assigned to receive aripiprazole augmentation (maximum dose 15 mg/day) or placebo for 12 weeks. Throughout the trial, the researchers assessed patients for extrapyramidal symptoms.

Forty (44%) of the 91 participants randomly assigned to aripiprazole achieved remission compared with 26 (29%) of 90 randomly assigned to placebo—a significant difference. Akathisia was the most common adverse effect of aripiprazole; 24 (26.7%) developed akathisia compared with 11 (12.2%) of participants assigned to placebo. Those who developed akathisia had higher depression severity at baseline. Aripiprazole was also associated with more parkinsonism; 15 people in the aripiprazole group (16.5%) developed parkinsonism compared with 2 (2.2%) in the placebo group. No clinical predictors or correlates for parkinsonism were identified. The researchers noted that most participants who developed akathisia improved over time, especially when aripiprazole dose was lowered.

“Fortunately, most older depressed patients who are prescribed aripiprazole will not develop akathisia, yet the emergence of these symptoms should be assessed carefully, particularly during initial dosage titration,” Hsu and colleagues concluded.

For related information, see The American Psychiatric Association Publishing Textbook of Psychopharmacology.

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Tuesday, June 26, 2018

Mobile App May Improve Mood, Motivation in Young People With Schizophrenia

Regular use of a mobile-based intervention may benefit young people with recent-onset schizophrenia spectrum disorders by improving their mood and motivation, according to a small study published in Schizophrenia Bulletin.

For the study, Danielle A. Schlosser, Ph.D., of the University of California, San Francisco, and colleagues recruited people aged 16 to 36 who had received a diagnosis of schizophrenia, schizophreniform, or schizoaffective disorder within the past five years. A total of 43 participants were randomly assigned to use a mobile intervention called PRIME (personalized real-time intervention for motivational enhancement) or to a wait-list group for 12 weeks. PRIME is a mobile app through which participants work toward self-identified goals (in areas of health and wellness, social relationships, and more) with the support of a virtual community of age-matched peers with schizophrenia spectrum disorders as well as motivation coaches. Participants in the PRIME group were encouraged to use the app daily, whether it be to message with coaches and/or peers or complete challenges.

Compared with the participants in the wait-list group, those who used PRIME experienced significant improvements in depression, defeatist beliefs, self-efficacy, and components of motivation, such as reward learning and anticipated pleasure. Over a 12-week period, participants were highly engaged in the platform, the authors reported. On average, participants logged in over four days/week and 5,152 direct messages were sent from participants to coaches. In terms of peer-to-peer interactions, participants initiated interactions with each other a total of 497 times.

“Many participants noted that it was the first time they had seen or interacted with other young people with an SSD [schizophrenia spectrum disorder], and they particularly appreciated being able to have on-demand coaching, as demonstrated by the qualitative feedback and this feature being rated as the most satisfying,” Schlosser and colleagues wrote. “[P]RIME may act as an important adjunctive intervention to treatment approaches that are usually more focused on treating the positive psychotic symptoms and offer a more holistic approach to improving outcomes for people with an SSD.”

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Monday, June 25, 2018

Mantram Therapy Found to Benefit Veterans With PTSD

A mindfulness-based therapy in which individuals learn to repeat personalized mantras to relax their thoughts appears to be more effective at reducing posttraumatic stress disorder (PTSD) symptoms than a problem-solving psychotherapy known as present-centered therapy, reports a study in AJP in Advance.

Mantram therapy is based on the premise that silently repeating a personally meaningful word or phrase (mantra) promotes relaxation, increases emotional regulation, and reduces stress. Present-centered therapy is a psychotherapy that focuses patients on the present to help them actively target daily challenges related to their past trauma and PTSD symptoms.

“Mantram therapy may be a valuable addition to current PTSD treatments because it incorporates some components of evidence-based treatments, yet without the trauma focus that can deter some clients,” wrote Jill Bormann, Ph.D., R.N., of the University of San Diego and colleagues.

Previous uncontrolled studies of veterans have suggested that mantram therapy can reduce PTSD symptom severity, help veterans manage sleep disturbances, and more. For the current study, Bormann and colleagues compared PTSD outcomes in veterans who were randomly assigned to either mantram therapy or present-centered therapy. A total of 173 veterans from two Veterans Affairs outpatient clinics diagnosed with military-related PTSD were assigned to receive eight individual weekly one-hour sessions of either mantram or present-centered therapy.

The mantram group experienced significantly greater improvements in their symptoms as assessed by the Clinician-Administered PTSD Scale at both the end of the study and at a two-month follow-up. Additionally, 59% of participants in the mantram group who completed the two-month follow-up no longer met criteria for PTSD, which was significantly higher than the 40% rate in the present-centered group. Participants who received mantram therapy also reported greater reductions in insomnia, a common occurrence in patients with PTSD, compared with those who received present-centered therapy.

Bormann and colleagues acknowledged that the study did not compare mantram therapy with either cognitive processing therapy or prolonged exposure, two evidence-based PTSD therapies currently used by the Veterans Health Administration. “It would be premature to draw any conclusions about the efficacy of mantram therapy compared with these established treatments, or other treatments, without head-to-head trials,” they wrote.

“Further assessment of mantram therapy in trials and real-world settings is clearly desirable, especially because mantram therapy may appeal to some veterans who may prefer therapies that are not trauma-focused, that include some element of spirituality, or that reduce sleep disturbances,” they concluded.

To read more about treatments for PTSD, see the Psychiatric News article “Propranolol Combined With Reactivation Therapy May Reduce PTSD Symptoms.”

(Image: iStock/asiseeit)

Friday, June 22, 2018

Police Shootings of Unarmed Blacks Adversely Impact Mental Health in Black Community

Police shootings of unarmed black Americans have adverse effects on the mental health of other black Americans in the general population, according to a study published Thursday in The Lancet. The report was released just two days after a police officer shot and killed Antwon Rose, an unarmed black teen who was fleeing a traffic stop in Pittsburgh.

Exposure to one or more police killings within a three-month period was associated with a 0.35 day increase in poor mental health days, according to the report, which combined data on police shootings with individual-level data from a nationally representative self-report survey on health. Adverse mental health effects were not observed among white respondents and resulted only from police killings of unarmed black Americans (not unarmed white Americans or armed black Americans).

“The observed adverse mental health spillover effects of police killings of unarmed black Americans could result from heightened perceptions of threat and vulnerability, lack of fairness, lower social status, lower beliefs about one’s own worth, activation of prior traumas, and identification with the deceased,” Jacob Bor, Sc.D., of Boston University School of Public Health and colleagues wrote. 

The researchers used self-reported race to identify black American respondents to the U.S. Behavioral Risk Factor Surveillance System (BRFSS), a nationally representative telephone survey that collects health data from U.S. adults. Information collected from the 2013-2015 BRFSS was combined with available data with the timing of police killings as reported in the Mapping Police Violence database, which has tracked police killings in the United States since 2013.

The primary exposure was the number of police killings of unarmed black Americans occurring in the three months prior to the BRFSS interview within the same state. The primary outcome was the number of days in the previous month in which the respondent’s mental health was reported as “not good.”

A total of 38,993 of the 103,710 black American respondents were exposed to one or more police killings of unarmed black Americans in their state of residence in the months prior to the survey. Each additional police killing of an unarmed black American in the respondent’s state of residence in the months prior to interview was associated with a 0.14 day increase in the number of poor mental health days. “Specifically, our estimates imply that police killings of unarmed black Americans could contribute 1.7 additional poor mental health days per person per year, or 55 million excess poor mental health days per year among black American adults in the [United States],” Bor and colleagues wrote. “Interventions are needed to reduce the prevalence of these killings and to support the mental health of communities affected when they do occur.”

Rahn Bailey, M.D.(pictured at above), the APA Assembly representative for the Caucus of Black Psychiatrists, told Psychiatric News he believes the study confirms what he and other black psychiatrists have observed anecdotally, both professionally and personally. “The study is timely and convincing and has real-world impact.” 

Thursday, June 21, 2018

APA Urges Members to Maintain Pressure on Administration Regarding Child Detentions

In an about-face, President Donald J. Trump signed an Executive Order yesterday halting his administration’s policy of separating migrant children from their parents who illegally cross the U.S. southern border. But Trump’s decision to continue his “zero tolerance” policy of border crossing will still place families into prison-like detention centers, perhaps long term.

It remains unclear what will happen to the more than 2,300 migrant children who have been separated from their parents since mid-May. Images of young children confined in steel cages and sleeping en masse on thin pads on concrete floors with aluminum-foil-like blankets sparked condemnation around the world, including from Pope Francis and all four living former first ladies.

APA led a coalition of mental health organizations in lobbying the administration to immediately halt its cruel policy of separating children from their parents at the U.S. border. “Children are dependent on their parents for safety and support. Any forced separation is highly stressful for children and can cause lifelong trauma, as well as an increased risk of other mental illnesses, such as depression, anxiety, and posttraumatic stress disorder,” wrote APA and 17 mental health organizations, including the American Association of Child & Adolescent Psychiatry and the American Psychoanalytic Association, in a letter sent yesterday to the departments of Justice, Homeland Security, and Health and Human Services.

“This is not an acceptable policy to counter unlawful immigration, and the administration must immediately rescind this course of action,” the letter continued. “We support practical, humane immigration policies that take into account what we know about the harmful, long-term psychological effects of separation on children and their families.”

The government, under a federal court order known as the Flores settlement, is prohibited from keeping migrant children in detention for more than 20 days. But Trump’s Executive Order instructs Attorney General Jeff Sessions to file a request to modify Flores so it can detain families long term while adjudicating the criminal proceedings of the parents for improper entry. When combined with asylum claim evaluations, such proceedings can take months or years to resolve.

“Many families crossing the United States border are fleeing war and violence in their home countries and are already coping with the effects of stress and trauma,” APA President Altha Stewart, M.D., said in a statement opposing the separation of children from parents at the border released May 30.

APA is calling on its members to keep up the pressure and prevent further trauma from being inflicted on these children and families. APA has posted a form in its Action Center that psychiatrists can use to urge the administration to halt its destructive immigration policies immediately. Access the Action Center form now.

(Image: iStock/Suriyawut Suriya)

Highlights From APA’s 2018 Annual Meeting: Issue #2

Stewart to Focus on APA’s Being a Leader on Issues of Diversity and Inclusion

Discrimination and implicit bias affect the psychological and physical health of not only psychiatry’s patients but also psychiatrists.

Read More >

Schatzberg Honored for Research Connecting Cortisol and Psychotic Depression

One of psychiatry’s leading researchers recounts the biopsychosocial work with which he has been involved in the search for more effective treatments.

Read More >

Most Americans Agree That Gun Violence Is Public Health Problem, Call for Action

Regardless of whether they are Democrats or Republicans, Americans believe Congress should take action to prevent mass shootings.

Read More >

Ensuring Patient, Staff Safety Begins With Supportive Management, Staff Training

Psychiatric hospitals with the best patient safety records spend time training nurses, use physical restraints as a last resort, and pay careful attention to staff involved with suicide watches.

Read More >

Digital Psychiatry Apps May Create New Burdens, Have Limited Efficacy Data

While mental health apps are proliferating, experts caution that they may create new legal responsibilities and question whether the hype is getting ahead of evidence supporting their use.

Read More >

Wednesday, June 20, 2018

Parent-Child Psychotherapy Leads to Improvements in Young Children With Depression

An adapted parent-child psychotherapy proven to help children with disruptive disorders may also reduce symptoms of depression in very young children, according to a study published today in AJP in Advance.

“The study provides very promising evidence that an early and brief psychotherapeutic intervention that focuses on the parent-child relationship and on enhancing emotion development may be a powerful and low-risk approach to the treatment of depression,” lead author Joan L. Luby, M.D., of Washington University School of Medicine in St. Louis said in a press release.

In standard parent-child interaction therapy (PCIT), a therapist first educates parents on ways to successfully interact with their child and then coaches parents as they practice these techniques with their child in an office setting. Previous studies show that PCIT is an effective way to treat disruptive behavior disorders in young children. Luby and colleagues wanted to know if adapting PCIT to focus on enhancing a child’s emotional competence and emotion regulation could reduce symptoms of depression in very young children with major depressive disorder.

Children aged 3 to 6 who met criteria for early childhood depression and their parents were randomly assigned to Parent Child Interaction Therapy–Emotion Development (PCIT-ED, n=114) or a waitlist group (n=115). In addition to depression, some of the children in the study met criteria for comorbid anxiety, attention-deficit/hyperactivity disorder, and/or oppositional defiant disorder at baseline. After the parent-child PCIT-ED pairs completed 12 PCIT sessions, they received training during which parents were taught how to validate their child’s emotions and help the child regulate these emotions. The researchers interviewed children and parents at the beginning and end of the 18-week study to assess the children’s psychiatric symptoms, ability to regulate emotions, and level of impairment and functioning. They also asked parents about how they coped with their child’s negative emotions and their own levels of stress and depression.

Compared with those in the waitlist group, children in the PCIT-ED group were found to have lower rates of depression, lower depression severity, and lower impairment at the end of the study. In addition, rates of comorbid disorders at trial completion, including anxiety disorders and oppositional defiant disorder, were significantly lower in the PCIT-ED group.

The therapy also appeared to have positive effects on the parents of the children with depression, Luby and colleagues reported. “Parents who received the active treatment displayed more emotionally focused parenting techniques and reported marked reductions in stress and a greater sense of positive responsiveness from their child. Also notable was that the treatment resulted in significant reductions in parental depression, even though this was not a direct target of treatment,” they wrote.

“The study findings suggest that early intervention for depression may be a window of opportunity to modify emotional functioning, utilizing the powerful influence of the parent-child relationship during this relatively neuroplastic developmental period to remediate depressive symptoms,” the authors concluded. “Given that depression is a chronic and relapsing disorder, these findings on an early, low-cost, low-risk psychotherapeutic intervention suggest that early identification and treatment of depressive disorders should become a public health priority.”

(Image: iStock/shapecharge)

Tuesday, June 19, 2018

Methadone, Buprenorphine After Opioid Overdose Associated With Lower Risk of Death

Treating patients who survive an opioid overdose with either methadone or buprenorphine appears to significantly reduce their risk of death for at least 12 months, but only a third of opioid overdose survivors may be receiving these medications, according to a report in the Annals of Internal Medicine.

“These findings suggest meaningful opportunities to improve engagement and retention in treatment of opioid use disorders after a nonfatal overdose,” wrote Marc Larochelle, M.D., M.P.H., of Boston Medical Center and colleagues.

Using the Massachusetts All-Payer Claims Database and several other linked Massachusetts state databanks, Larochelle and colleagues identified adults aged 18 and older who survived an opioid overdose between January 2012 and December 2014. The researchers also identified those who received medication for opioid use disorder, including methadone maintenance treatment (MMT), buprenorphine, or naltrexone.

In the 12 months after a nonfatal overdose, 2,040 people (11%) enrolled in MMT for a median of five months, 3,022 people (17%) received buprenorphine for a median of four months, and 1,099 persons (6%) received naltrexone for a median of one month.

Over 12 months of follow-up, 807 participants died of any cause and 368 died of an opioid-related overdose. Compared with individuals who received no treatment for opioid use disorder, those who received MMT or buprenorphine were less likely to die of any cause or of an opioid-related cause; reliable associations between treatment with naltrexone and all-cause and opioid-related death could not be ascertained owing to the small number of patients receiving naltrexone—a limitation to the study the researchers acknowledged.

Larochelle and colleagues noted that rates of treatment initiation are inversely proportional to the lag in time between being offered treatment and being able to start. “New models that offer treatment initiation and linkage to care from emergency department and inpatient settings have demonstrated increased treatment engagement,” they wrote. “Our findings also show that treatment initiation without retention undermines benefits.”

In an accompanying editorial, Nora Volkow, M.D., and Eric Wargo, Ph.D., of the National Institute on Drug Abuse, offered several strategies to increase medication-assisted therapy delivery to people at risk for opioid overdose. “A great part of the tragedy of this opioid crisis is that, unlike in previous such crises America has seen, we now possess effective treatment strategies that could address it and save many lives, yet tens of thousands of people die each year because they have not received these treatments,” they wrote. “Ending the crisis will require changing policies to make these medications more accessible and educating primary care and emergency providers, among others, that opioid addiction is a medical illness that must be treated aggressively with the effective tools that are available.”

For related information, see the Psychiatric News article “Why Aren't More Physicians Prescribing Buprenorphine?” and the Psychiatric Services article “Three-Year Retention in Buprenorphine Treatment for Opioid Use Disorder Among Privately Insured Adults.”

(Image: iStock/shironosov)

Monday, June 18, 2018

Autistic Traits Associated With Elevated Depression in Youth Aged 10 to 18

At age 10, children with autism spectrum disorder (ASD) and those with high levels of autistic traits have more depressive symptoms than children in the general population, reports a study published in JAMA Psychiatry. These elevated depressive symptoms persist in the children until they are 18 and are significantly influenced by bullying.

“[F]urther research into the role of traumatic experiences, such as bullying, and the utility of interventions to reduce bullying or address its adverse effects could have the potential to reduce the burden of depression in this population,” wrote lead author Dheeraj Rai, Ph.D., of the University of Bristol and colleagues. 

For this study, Rai and colleagues assessed data from the Avon Longitudinal Study of Parents and Children (ALPSAC), which tracked over 15,000 children born in the Bristol area between 1990 and 1992 and their parents until the children turned 18. As part of ALSPAC, investigators conducted periodic clinical assessments and had parents and children complete self-report questionnaires for a range of behavioral issues, including ASD and depression.

The final dataset for the study included 8,087 children. Of this group, 96 children were diagnosed with ASD, 546 had social communication impairments, 526 had problems with speech coherence, 419 displayed repetitive behaviors, and 801 had poor social temperament.

Children with ASD or any of the four autistic traits had higher depressive symptom scores than the general population at age 10, as assessed by the Short Mood and Feelings Questionnaire (SMFQ). The SMFQ scores continued to rise over time, though by age 18 only those with social communication impairments had a significantly higher rate of diagnosed depression than the youth in the general population (1.68 times the risk).

At age 10, the children with ASD and autistic traits who reported being bullied had the highest average SMFQ scores; likewise, youth with social communication impairments who reported being bullied in childhood or adolescence were more likely to have a diagnosis of depression at age 18.

“These findings add to the evidence highlighting a higher burden of depression and also suggest a potentially modifiable pathway, through bullying,” Rai and colleagues wrote. “However, gaps remain in our understanding of the measurement and phenomenology of depression in individuals with autism, which could be a priority for future research. Further work could also focus on improvements in psychological and pharmacological management of depression in ASD.”

To read more about this topic, see the Psychiatric News article, "Social Skills Therapy for ASD Shows Modest Benefits in Routine Settings."

(iStock/Aleksander Rybin)


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